Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Dementia


Related Terms

  • Alzheimer's-type Dementia
  • Chronic Organic Brain Syndrome
  • Multiple Cognitive Deficits
  • Senile Dementia
  • Senile Dementia of the Alzheimer Type
  • Vascular Dementia

Differential Diagnosis

  • Alcohol/substance abuse
  • Amnestic disorders
  • Delirium
  • Depressive disorder (pseudodementia)
  • Focal brain syndromes
  • Malingering
  • Normal aging

Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Neurologist
  • Occupational Therapist
  • Physical Therapist
  • Psychiatrist

Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Depressive disorders
  • Infection
  • Other psychiatric disorders
  • Vascular disease

Factors Influencing Duration

Diagnosis and treatment of a treatable dementia may lead to restored mental function. The severity of dementia and extent of available social supports can influence disability. Most forms of dementia are incompatible with gainful employment.

Medical Codes

ICD-9-CM:
290 - Senile and Presenile Organic Psychotic Conditions
290.0 - Senile Dementia, Uncomplicated, NOS, Simple Type
290.1 - Dementia, Presenile; Brain Syndrome with Presenile Brain Disease
290.10 - Presenile Dementia, Uncomplicated, NOS, Simple Type
290.11 - Presenile Dementia with Delirium; Presenile Dementia with Acute Confusional State
290.12 - Presenile Dementia with Delusional Features; Presenile Dementia, Paranoid Type
290.13 - Presenile Dementia with Depressive Features; Presenile Dementia, Depressed Type
290.2 - Senile Dementia with Delusional or Depressive Features
290.20 - Senile Dementia with Delusional Features; Senile Dementia, Paranoid Type; Senile Psychosis NOS
290.21 - Senile Dementia with Depressive Features
290.3 - Senile Dementia with Delirium; Senile Dementia with Acute Confusional State
290.4 - Dementia, Arteriosclerotic
290.40 - Vascular Dementia, Uncomplicated; Arteriosclerotic Dementia NOS, Simple Type
290.41 - Vascular Dementia with Delirium; Arteriosclerotic Dementia with Acute Confusional State
290.42 - Vascular Dementia with Delusions; Arteriosclerotic Dementia, Paranoid Type
290.43 - Vascular Dementia with Depressed Mood; Arteriosclerotic Dementia, Depressed Type
290.9 - Senile Psychotic Condition, Unspecified
291 - Alcoholic Psychoses
291.2 - Alcoholic Dementia, Other
292 - Drug Psychoses; Drug-induced Mental Disorders
292.8 - Drug-induced Mental Disorders, Other Specified
292.82 - Drug-induced Persisting Dementia
293 - Transient Mental Disorders Due to Conditions Classified Elsewhere
293.9 - Transient Mental Disorder in Conditions Classified Elsewhere, Unspecified; Organic Psychosis, Infective NOS, Posttraumatic NOS, Transient NOS; Psycho-organic Syndrome
294 - Persistent Mental Disorders Due to Conditions Classified Elsewhere
294.1 - Dementia in Conditions Classified Elsewhere; Dementia of the Alzheimers Type
294.11 - Dementia in Conditions Classified Elsewhere with Behavioral Disturbance; Aggressive Behavior; Combative Behavior; Violent Behavior; Wandering off
294.8 - Persistent Mental Disorders Due to Conditions Classified Elsewhere, Other; Amnestic Disorder NOS; Dementia NOS; Epileptic Psychosis NOS; Mixed Paranoid and Affective Organic Psychotic States
299 - Pervasive Developmental Disorders
331 - Cerebral Degenerations, Other
331.1 - Cerebral Degenerations, Other; Frontotemporal Dementia
331.11 - Cerebral Degenerations, Other; Frontotemporal Dementia; Picks Disease
331.19 - Cerebral Degenerations, Other; Frontotemporal Dementia; Other Frontotemporal Dementia; Frontal Dementia
331.8 - Cerebral Degeneration, Other
331.82 - Cerebral Degeneration, Other; Dementia with Lewy Bodies; Dementia with Parkinsonism; Lewy Body Dementia; Lewy Body Disease

Overview

Dementia is a general term describing a group of disorders in which memory and thought processes (cognition) become impaired for a period of at least 6 months. Unlike mental retardation, dementia involves a change in thinking abilities relative to baseline.

Dementia can be caused by about 50 different disorders, but 50% to 70% of cases are caused by Alzheimer's disease, and 20% to 30% by vascular disease. In many forms of dementia, such as Alzheimer's disease, Lewy body disease, and other neurodegenerative disorders, symptoms develop slowly, are relatively stable rather than fluctuating, and continue into a slow decline. However, other forms of dementia, such as vascular dementia associated with small strokes (multi-infarct dementia) may begin abruptly and worsen in stepwise fashion, with relative stability between each decline. In dementia secondary to head trauma or encephalitis, memory problems are worst at the outset, and remain relatively stable or may even improve with time.

Impaired memory is a prominent and early symptom of dementia. New skills and knowledge are difficult to learn, while old skills and knowledge are eventually lost. Valuables may be lost, such as a wallet or keys. The person may become lost, even in familiar surroundings. Late in dementia, individuals may forget their occupation, family members, or even their name. Other symptoms are difficulty naming objects or people (anomia), rambling speech, difficulty performing certain activities (apraxia), or failure to recognize certain objects (agnosia). Executive functions, such as thinking abstractly, planning, and initiating complex activities, can be impaired. Poor judgment and insight are common. The individual usually has little or no awareness of memory loss or other abnormalities. Individuals have an unrealistic view of their capabilities or their future. For example, they may talk of starting a business or driving. There can be mood and sleep disturbances. False beliefs (delusions) are common, especially paranoid delusions involving others stealing from them or conspiring against them. Individuals with dementia may have further deterioration of cognitive abilities with stress, either physical stress such as a viral illness or minor surgery, or psychological stress such as bereavement.

Alzheimer's disease is the most common cause of dementia, followed by Lewy body disease (DSM-IV-TR 832). Other possibilities include stroke and Parkinson's disease, Huntington's disease, brain injury, tumor, infection (AIDS, syphilis), autoimmune diseases such as lupus, hypothyroidism or other endocrine diseases, liver disease, a neurological disease such as multiple sclerosis, normal pressure hydrocephalus, or heavy metal poisoning with lead or mercury. Dementia could also be a long-lasting effect of drug or alcohol abuse.

Incidence and Prevalence: Prevalence ranges from about 1.5% for individuals age 65 to 69, up to 16% to 25% for those over 85 (DSM-IV-TR 832).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The occurrence of dementia increases with age. The age of onset is usually late in life, with the highest risk above 85 years.

Source: Medical Disability Advisor



Diagnosis

History: History should be obtained from or at least corroborated by the family or caregivers, as the individual often lacks judgment and is unaware that anything is wrong. The individual also may be in psychological denial, unwilling to accept what may he or she fears may be happening. The diagnosis of dementia involves a deterioration in memory from baseline. Depending on the underlying cause of dementia, memory and thinking may get worse gradually or in stepwise fashion, or may be worst at the outset, with stability or even gradual improvement with time. Other symptoms may include difficulty recognizing people or objects, performing skills, or organizing one's life. These impairments cause a decline in social or occupational functioning, including taking care of basic tasks of life such as bathing, dressing, and eating. Diagnosis requires the presence of memory impairment plus one or more of the following: language disturbance (aphasia); inability to carry out motor activities in spite of preserved motor function (apraxia), such as inability to use a toilet; inability to identify objects (agnosia); or inability to plan or organize activities (impaired executive functioning). History should also focus on alcohol or medication use that could be affecting cognitive function.

Physical exam: The exam could show signs of an underlying disease, such as vascular disorders or vitamin deficiencies. A lack of facial expression (flat affect) might be present. On neurological examination, abnormalities might include symmetrically abnormal reflexes (frontal lobe release signs). In dementia caused by vascular disease, multiple sclerosis, or autoimmune conditions, there might be multifocal findings reflecting abnormalities in several different brain structures. These might include asymmetrical reflexes, weakness on one side, or abnormalities in the cranial nerves supplying strength and sensation to the head and neck. In dementia caused by a brain tumor, single stroke, or head trauma, the neurological examination might show abnormalities restricted to a single location in the nervous system.

Tests: Tests include mental status examinations such the Folstein Mini Mental Status Exam (MMSE) or more detailed and sensitive neuropsychological testing to document cognitive impairment. Neuroimaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), may reveal shrinking of brain substance (cerebral atrophy), strokes, tumors, or other abnormalities. Positron-emission tomography (PET) or single photon emission computed tomography (SPECT) scans, thought to be more of a research tool than CT and MRI, may show functional changes in parts of the brain involved in Alzheimer's disease or thought processing (frontal, temporal, or parietal lobes). Blood work may show treatable endocrine, metabolic, autoimmune, or infectious causes, such as hypothyroidism, vitamin B12 or folate deficiency, syphilis, or lupus. Electroencephalogram (EEG) may be helpful in those forms of dementia with specific EEG patterns, such as Creutzfeldt-Jakob disease. Spinal tap (lumbar puncture) is usually unnecessary, but may help diagnose autoimmune or infectious forms of dementia. Research suggests that certain markers in spinal fluid may be elevated in Alzheimer's disease.

Source: Medical Disability Advisor



Treatment

Treatment is aimed at slowing the effects of any underlying cause. Vascular dementia, for example, can be treated with drugs that lower blood pressure and anticoagulants; preventive treatment for this condition includes diet, exercise, and control of diabetes. Approximately 20% of all cases of dementia are treatable.

Treatment for dementia of the Alzheimer's type has not yet been effective. Donepezil hydrochloride has been shown to extend the functional ability of some individuals with mild to moderate Alzheimer's disease. Newer medications, such as rivastigmine, ziprasidone, and quetiapine are being studied for their effectiveness in stabilizing the symptoms of dementia. A regular and consistent schedule of activities can help some individuals avoid emotional outbursts, while lithium, anticonvulsant medications, or antipsychotics may be needed in others. Teaching the caregiver strategies for coping with the physical, emotional, and legal burdens of dementia is a crucial part of the treatment plan. Educational materials, support groups, and social service intervention may help prevent caregivers from becoming depressed or anxious, which is a significant risk. Identifying individuals at risk for dementia, such as those with a strong family history, may allow earlier intervention with preventive medications such as statins or anti-inflammatory drugs. These might theoretically help prevent dementia in individuals at risk, based on epidemiologic studies showing decreased risk of dementia in individuals using these medications.

Source: Medical Disability Advisor



Prognosis

Dementia is usually irreversible and often progressive, although 20% of cases are treatable, demanding a thorough workup as soon as possible. Early diagnosis may allow symptoms to be decreased or delayed with treatment, but the underlying deterioration usually continues. Other benefits of early diagnosis include more effective planning by the family, and prevention of motor vehicle or other accidents due to driving while impaired.

Source: Medical Disability Advisor



Rehabilitation

Physical therapy might be helpful if the individual has problems with gait and balance. Occupational therapy might assist the individual adapt to simpler communication or self-care skills. Relaxation techniques might be helpful in decreasing stress. However, demented individuals often are too impaired to allow carryover from one therapy session to the next, particularly in progressive dementia such as Alzheimer's disease. Rehabilitation is more appropriate in static forms of dementia such as those associated with head trauma, a single stroke, or encephalitis. Mildly to moderately demented individuals may benefit from "day groups" stressing orientation, social interaction, and reminiscence therapy, such as listening to music which was popular in their youth, or talking about work, parenting, or other experiences relating to earlier life.

Source: Medical Disability Advisor



Complications

Individuals with dementia can become aggressive or violent toward others. Suicide is possible in the early stages when individuals are still capable of carrying out a plan. Falls, injuries, and other accidents are common because of impaired judgment and coordination. When demented individuals lose control of their bowels and bladder (become incontinent), they are more likely to get urinary infections and bedsores (decubitus ulcers), and to be institutionalized. Bedridden individuals with dementia are more likely to develop pneumonia, blood clots (thromboembolism), and joint immobility (contractures). Vascular dementia is likely to be complicated by additional strokes and heart attack (myocardial infarction), which may be fatal. Poor appetite and difficulty manipulating utensils may lead to malnutrition or dehydration. Seizures may occur in vascular dementia or in dementias related to autoimmune disease, infection, or trauma.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Those in very early stages might function better with set routines, clear instructions, and well-learned tasks. Individuals in later stages of dementia are usually not employable.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was a thorough workup done to identify and exclude all treatable causes of dementia?
  • Has history focused on alcohol or medication use that could be affecting cognitive function?
  • Does individual have difficulty recognizing people or objects, performing skills, or organizing daily activities of life?
  • On neurological exam, were abnormalities present such as symmetrically abnormal reflexes (frontal lobe release signs)?
  • Were conditions with similar symptoms ruled out?
  • Was diagnosis of dementia confirmed?

Regarding treatment:

  • Are underlying cause(s) responding to appropriate treatment? If not, should treatment plan be re-evaluated?
  • Has individual received a trial of medications now available that may help slow the development of cognitive deficits?
  • Does individual have hallucinations, delusions, or agitation that may respond to appropriate medications?
  • Was caregiver taught strategies for coping with the physical, emotional, and legal burdens of dementia?
  • Are educational materials, support groups, and social service intervention being utilized to help prevent caregiver from becoming depressed or anxious?

Regarding prognosis:

  • Did early diagnosis allow symptoms to be decreased or delayed with treatment?
  • Did early intervention include treatment with preventive medications such as statins or anti-inflammatory drugs? If diagnosis is uncertain, is individual still at risk for dementia?
  • Is individual a candidate for preventive medications?
  • Was family able to effectively plan strategies for coping with the physical, emotional, and legal burdens of dementia?
  • Would caregiver(s) benefit from social service intervention? Enrollment in a support group?
  • Does individual have a coexisting condition that may impact recovery such as depression, concurrent substance abuse, or toxic effects of alcohol or drugs on the brain?
  • Are vascular disorders, infections, and other acute or chronic illnesses present that could exacerbate dementia symptoms?

Source: Medical Disability Advisor



References

Cited

Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Source: Medical Disability Advisor






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